EMPLOYMENT APPLICATION POSITION DESIRED: Today s Date: _ Professional License/Certification # (State of California): Other State License/Certification #: Issue Date: Exp. Date: Issue Date: Exp. Date: Has your license/certification ever been revoked or suspended? YES NO If yes, state reason(s), date of revocation or suspension, and date of reinstatement: Available to Work: Full Time Part Time Per Diem Temporary Shift Available to Work: Days Evenings Nights If hired, date you can start: If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country? YES NO Name: PERSONAL DATA (Last Name) (First Name) (Middle Initial) Address City State Zip Code Telephone Number Message Telephone Number Number Web Address Emergency Telephone Do you have any relatives working at Paradise Valley Hospital (PVH)? YES NO if yes, please provide name(s) and which facility: Are you at least 18 years old? YES NO (If under 18, hire is subject to verification that you are of minimum legal age.) Were you previously employed at the facility in which you are applying? YES NO If yes, reason for leaving: Have you worked under another name(s)? YES NO If answer is yes, what name(s) did you use: How did you hear about us? Name of the person who referred you to us: Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation? YES NO If no, describe the functions that cannot be performed. (Note: We comply with state and federal disability laws and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire might be subject to passing a medical examination and to skill and agility tests.)
Have you ever been convicted of a criminal offense? (Convictions that have been sealed, expunged, dismissed or eradicated by statute or court order, convictions for marijuana related offenses that are more than two years old and information pertaining to any arrest or detention which did not result in conviction as a result of referral to and participation in any pre-trial or post-trial diversion program need not be listed) YES NO If yes, state nature of the crime(s), when and where convicted, and disposition of the case. NOTE: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position applying for may, however, be considered. Have you been excluded from participating in the Medicare or Medicaid programs? YES NO if yes, please provide reason(s): RECORD OF EDUCATION Name and address of Schools, Colleges, Trade, Business or other schools attended; also list apprenticeships/internships, if applicable: Number of years completed and major: Diploma/Certificate/ Degree obtained: EMPLOYMENT RECORD In the space provided below, list all employment or volunteer service for the past 10 years, give most recent first. Attach additional sheet(s), if necessary. From: Starting Salary: Ending Salary: Starting Salary: Ending Salary:
Starting Salary: Ending Salary: Starting Salary: Ending Salary: Many of our clients do not speak English. Do you speak, write or understand any foreign languages? : YES NO Other Special Skills/Qualifications that you feel make you especially suited for work here: PERSONAL REFERENCES In the space below, give personal references (other than relatives or former employers) Name Address Period Known Occupation Telephone Number
Please Read Carefully, Initial Each Paragraph, and Sign Below I understand that nothing contained in this application or in the granting of an interview is intended to create an offer of employment or an employment contract between Paradise Valley Hospital and myself for either employment or for any other benefit. I understand that employment with Paradise Valley Hospital is considered to be At Will employment. As such, I understand that if I become employed by Paradise Valley Hospital, my employment will not be for a specified term and will be at the mutual consent of Paradise Valley Hospital Center and myself. Accordingly, either Paradise Valley Hospital or I may terminate the employment relationship at will, with or without cause, at any time, with or without notice. I understand that no one, other than the CEO of Paradise Valley Hospital has the authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing. I understand that any change to the At Will nature of my employment should I be hired would require the express written approval of the CEO of Paradise Valley Hospital. I hereby certify that all statements made in this application are true and correct to the best of my knowledge. I authorize Paradise Valley Hospital to investigate all statements contained in this application. I understand and agree that any false statements, misrepresentations, or omissions of facts appearing on this application or any other employment form or medical information/examination form will result in immediate dismissal or removal of my application for consideration. I authorize Paradise Valley Hospital to secure information about my background and/or experience with former employers, education institutions, agencies and government entities and for those parties to provide information concerning my background and/or experience, and I hereby release Paradise Valley Hospital and all other parties from any liability arising therefrom. I understand that any offer of employment will be conditioned upon my successful completion of a preemployment criteria including a physical examination, a substance abuse test, a criminal records check, and other informational items as may be required by Paradise Valley Hospital. I understand that failure to take or pass a physical examination, substance abuse test, criminal background check, or other items legally required by Paradise Valley Hospital at any time during my employment may result in immediate dismissal. I further agree to abide by the existing rules of Paradise Valley Hospital and any rules and regulations as may become effective during my employment. I understand that if I am offered employment by Paradise Valley Hospital, I will be required to sign an Arbitration Agreement as a condition of employment. This agreement will provide that any and all disputes between myself and Paradise Valley Hospital, including but not limited to disputes arising out of or relating to my employment or the termination of my employment, will be subject to resolution only through final binding arbitration in accordance with the Arbitration Agreement, including applicable rules and regulations of the American Arbitration Association. In signing this form, I certify that I understand all of the information requested and statements made within this application. Applicant's Signature: Date:
APPLICANT DATA COLLECTION FORM State law requires employers to obtain information from each job applicant concerning the applicant s race, sex, national origin and the job for which the applicant is applying. This form is used to provide each applicant with an opportunity to furnish such information voluntarily. Accordingly, if you decide not to provide the information, your decision will not be held against you. All information that is provided will be used for record-keeping purposes only and will be kept separate from an employee s main personnel file. Furthermore, such information will not be used for any discriminatory purpose. If you choose to provide the information, please complete the following: Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American (Not Hispanic or Latino) A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment. Two or More Races Sex: Male Female Position Applied For: Date: